"Appreciating the digital lives of patients"

There is an increasing demand for us, as clinicians, to understand the digital lives of our patients. The framework I have come to employ in my practice is simple and, I think, not radical: to regard the patient’s relationship with the virtual world with the same curiosity, scrutiny, and compassion that one affords to their relationship with the corporeal one. This can be easier said than done, as there is substantial cultural and political noise that interferes with such a straightforward premise. Technologists, one on hand, espouse the transcendent nature of digital devices and media: how they make us better, smarter, and stronger. Conservative alarmists, alternately, decry our increased reliance on digital spaces as the decay of traditional values and an omen of society’s downfall: we are becoming antisocial, vain, and ugly — as though these qualities were new to the human condition.

As psychoanalytic psychologists it is our duty to maintain a heuristic of skepticism and see beyond the binary assertions of technology-as-savior or technology-as-destroyer, and instead focus on the paradoxical truth: digital space is both new and old, in that it provides us with novel ways to continue to be ourselves. As I have written about elsewhere (Kriss, 2016) with specific respect to videogames, the virtual world can offer a boundaried emotional experience akin to Winnicott’s (1971/2005) notion of potential space; a kind of proto-life in which experiences are simultaneously real and unreal, felt but not overwhelming. The fact of the matter is that all of our patients make some contact with this other world; we are symbiotically linked to it; parts of ourselves are uploaded to cyberspace as we curate our public personas, comment anonymously on articles and blogs, or simply play games idly on our phones. The question is no longer whether the digital is relevant to our patients but rather in what ways is it relevant.

Of course, this is not to deny that some people’s use of digital space is problematic. But understanding the nature of the problem — and therefore potentially making ourselves available to facilitate change — requires us to discard the simplistic cause-and-effect notions that technologists and alarmists propagate (technology leads to betterment or technology leads to disarray, respectively). We do this routinely with other aspects of psychic life, helping our patients to see beyond a reified sense of self. For instance, someone begins treatment with the narrative, “I am this way because my mother was cold and withholding, and as the past cannot be undone, I cannot change.” Is this any different from a mantra of “I am this way because I spend too much time looking at my phone, and as the digital world has sunk its claws into me, I cannot change”?

Much of the clinical discourse surrounding our relationships with digital selves occurs in the language of addiction theory: she is “hooked” on social media; he is “addicted” to the internet; they “can’t stop” playing this game. Crucially, the construct of addiction is centered around the idea that, while people vary in vulnerability depending on heredity and life experience, the addictive property lies within the thing itself. This is a compelling notion for substances like alcohol, nicotine, or cocaine — which chemically influence the brain to motivate future use — or even certain behaviors like gambling — which is specifically connected to the culturally valued promise of wealth acquisition.

Digital life doesn’t quite fit the bill. The internet is not a chemical you ingest, and thereby cannot exert immediate and consistent effects on the brain; nor do videogames promise material rewards that justify the amount of time so-called “addicts” put into them. The chief limitation to understanding digital addiction, then, is our use of the word “addiction.” It immediately frames the activity as a kind of infectious substance, obscuring what is really going on: compulsion. It is a small semantic change that carries a major shift in perspective. It is not the digital world which won’t release the individual from its clutches, but the individual who cannot bring herself to leave the digital world.

From a classical psychoanalytic perspective, a person engages in repetitive play as a means of recreating some trauma around which she feels “stuck,” in an unconscious effort to master the situation (Freud, 1920; Waelder, 1933). If playing fails to resolve her conflicted feelings, a compulsive loop can develop in which the person can neither abandon nor conquer the “game.” Each person has a unique reason for seeking solace in digital space, and sometimes this need is so intense that the behavior escalates to a level of pathological compulsion. But it is in understanding the internal motivation that relief can be found, not through condemning the digital world as inherently corruptive. For most people we treat, virtual space does not cause distress or play a significant role in their presenting problems; it simply occupies a portion of their psychic life, which, however big or small, should be seen as important by any empathic clinician.

WORKS CITED

Freud, S. (1920). Beyond the pleasure principle. S.E., 18, 3–64.

Kriss, A. (2016). The player and the game: Compulsion, relation, and potential space in video games. Psychoanalytic Psychology, 33(4), 571-584.

Alexander Kriss has written a timely plea for a more enlightened approach to our patients’ digital lives. He joins a number of clinicians, therapists, and psychoanalysts (including contributors such as Essig 2012, Lemma 2015 and myself (Gilmore 2017 in press; Meersand and Gilmore 2017, in press) in pointing out that the technocultural era is here to stay; indeed the daily experience of anyone living in our society is seamlessly mediated and continuous with digital space. There is no longer a distinction between virtual and actual. But like anything else, digital life can become an overwhelming focus, to the detriment of family relationships, school or employment, and physical well-being. Kriss devotes a good part of his essay to an argument against the notion of internet/videogame addiction (which I will call IA), basing his contention on the absence of the chemical component that is the active agent in substance addictions. Like some researchers in the field (Aladwani and Almarzouq 2016), he prefers to describe excessive video gaming, social networking and the like as compulsions, distinguishing them from addictions by this designation.

Here he enters a debate that has a significant, albeit brief history in psychiatry and in the formulation of the DSM-V, where IA did not make the grade for an official addiction diagnosis. Heated controversy continues about this decision (see, for example, Pies 2009), especially as another behavioral addiction, gambling, was included among the addiction diagnoses. What is the argument in favor of the inclusion of AI? For one, in severe cases, interruption of usage can produce the array of behaviors associated with withdrawal. There is evidence that excessive users develop tolerance and that the activity has deleterious effects on schoolwork, job performance and relationships. There is also growing evidence that excessive immersion in video gaming (Han et al 2011; Ko et al 2009)), social networking (Vink et al 2015), and smartphone use (Liu et al 2016), to name a few examples, can produce brain changes consistent with other addictions. The literature from Asia has made this argument for many years, reporting smartphone addiction in infants, with characteristic brain changes (Park and Park 2014). There is no doubt that these activities produce altered mental states.

What is the advantage of calling these extreme users addicts? In my opinion, there is a considerable difference in the conceptualization and the treatment of the problem; Kriss’s description of the individual dynamics behind compulsions and the need to understand these dynamics are important, but working on this understanding, even with an insightful and cooperative patient, is of only limited benefit if the patient is addicted; it certainly does not treat the addiction itself. Addiction is the threshold problem that must be addressed in order work on psychodynamics. To quote a beloved in-patient psychiatrist, now deceased, no therapy is as good (and as immediately effective) as a drink. This applies to any addictive behavior that creates cravings, alters mood, induces state changes, produces withdrawal, and, of course, is perpetuated by compulsion. Addiction requires behavioral treatment; the dynamics can be addressed simultaneously or afterward.

While my original piece focused on theory, Karen Gilmore brings up the equally important issue of technique. I agree with her wholeheartedly that for many suffering from digital compulsions, behavioral intervention may be a necessary first step to successful treatment. As with any acute situation, serious problems in daily functioning must be remediated before more reflective understanding can develop. I disagree simply with Gilmore’s suggestion that in order to engage with behavior and symptoms on a technical level, one must favor addiction over psychodynamics on a theoretical level. My argument is not that problems with digital life should only be addressed through formal psychoanalytic techniques such as interpretation, but that regardless of technique it is essential for the clinician — and ultimately the patient — to appreciate the problem’s point of origin.

About the Authors

Alexander Kriss, Ph.D. is a clinical psychologist and writer. He serves as an adjunct professor at Fordham University and clinical supervisor at The New School for Social Research and the City College of New York. For more information on Dr. Kriss’ private practice, visit www.alexkriss.com

Dr. Karen Gilmore is currently a Clinical Professor of Psychiatry and Senior Consultant at the Columbia University’s Center for Psychoanalytic Training and Research. She is the founder and past Director of its Child Division. She is a Training and Supervising Analyst at the Columbia institute. She is the author of a number of papers on development and co-authored two books on the topic recently published by American Psychiatric Press and Oxford University.